Better support is needed for coeliacs to increase the effectiveness of the gluten-free diet - and culturally appropriate new product development (NPD) is crucial, says one gastroenterology dietitian.
There has been some negative press around gluten-free diets, with several studies raising concerns about its impact on metabolic risks such as obesity, diabetes and cardiovascular disease (CVD).
However, Nick Trott, a gastroenterology dietician at the Royal Hallamshire Hospital, Sheffield, warns against taking the headlines at face value, stressing that demonisation of gluten-free foods is potentially far more dangerous for coeliac sufferers.
He told Fi Global Insights: “There have been some systematic reviews including a meta-analysis last year, and it seems that once coeliacs move to a gluten-free diet, a subset of them are more at risk for metabolic syndrome. But when you look at the data in this paper, only six to 12% become overweight or obese, which is certainly no more than you would expect within the general population.”
In terms of CVD, he said that although there does appear to be an increased risk among coeliacs, none of the mechanisms that would be driven by diet appear to be the cause.
He also pointed out that there have been some counter studies, including a large study that concluded there is no increased risk for type II diabetes post-diagnosis long-term on a gluten-free diet.
“When you actually look at the outcomes of the research, it’s quite a mixed picture, so I think we’ve got to be very careful with the messaging around this,” he said.
One of the potential dangers of demonising the gluten-free diet is that people who have coeliac disease or a gluten intolerance will not come forward for screening or will choose not to avoid gluten, resulting in far more serious health consequences.
“I think what is getting lost is the message that the risks of the gluten-free diet are vastly outweighed by the risks of non-treatment, which include effects on bone health, osteopenia and osteoporosis, as well as hematinic and mineral deficiencies. That is why, when we look at the effect of the gluten-free diet, we always have to balance it with why we are doing it,” he said.
With this in mind, Trott believes that the challenge that really warrants attention is that of improving support for the gluten-free diet.
“In many ways coeliac disease is a Cinderella condition. It comes with a significant treatment burden and people aren’t getting the support they need. When we follow up with patients, we often find that either they are not managing the diet very well, or they are not adhering to it, or they are following the diet in such a way that does not serve their underlying health. Yet rather than looking at these areas, people are blaming the diet itself.”
Support can take many forms and the food industry has a key role to play through product development and education.
One area where he believes the industry could make a difference is to offer more gluten-free products that are representative of different cultural backgrounds.
“We are seeing coeliac disease increasingly being diagnosed in diverse populations, and so we also need to ensure people from different ethnic backgrounds have access to gluten-free options that represent their nutritional cultural heritage. I think that strategies for representing what is culturally significant for people has been lacking in the past, in medical, dietetic and food manufacturing terms.”
Trott says that it is also important that people are able to follow a version of the diet that will best support their metabolic health.
“For example, someone with a family history of type II diabetes will need a diet that addresses the metabolic and nutritional components,” he notes.
He applauded the progress that has been made in improving the nutritional quality of gluten-free foods, but said there is still work to be done – particularly at the cheaper end of the market.
“I would say there is a bit of a dichotomy between the higher end products that cost more and have a better nutritional profile, and the cheaper items, which don’t always have the best nutritional profile. I think companies producing foods for the lower cost area of the market need to think how they can improve those products.”
In some cases, he said it might just be a case of reviewing what base grains are being used.
“Are they using a lot of rice flour or tapioca starch, for example? If so, perhaps they can look at innovation with different grains that are likely to have a better nutrient and metabolic profile, such as sorghum or quinoa.”
However, he acknowledged that with many gluten-free products already prohibitively expensive for some consumers, cost is a limiting factor for innovation in this space.
Here, he thinks that educating consumers about the complexities and costs of gluten-free food production might help.
“People aren’t aware of what gluten-free production involves, in terms of additional testing and training, cleaning protocols, regulatory requirements, and production techniques. If we could communicate that message, it would help people understand why there is an increased cost.”
Moving to the opposite end of the nutritional scale, Trott is also of the view that less healthy products can have a valid role in the gluten-free diet, for boosting emotional health and compliance.
Ensuring that those following a gluten-free diet can access foods that add to their quality of life is important, he said, citing some unpublished data which found that coeliacs are more likely to have a poorer food related quality of life.
“It’s very important that there is a range of food options out there to support people not only with their metabolic health, but also with their food related quality of life. If they can go out and order a gluten-free pizza with their friends on a Friday night, that is going to support their cognitive emotional health.”
